The one question to get to the heart of a patient’s true concern

I was stumped. Of course, that happens almost daily during intern year. The patient was a grinning three-year-old boy who was tearing around the urgent care exam room, yet his mother kept her lips pursed and wouldn’t look me in the eyes. I had already given her careful reassurance about her child simply having a cold and recommended supportive care with chicken soup and plenty of fluids, but her body language radiated dissatisfaction.

I ducked outside and presented the case to my attending, an experienced pediatrician. At the conclusion of my story I found myself admitting, “I feel like I’m missing something.”

When we returned to the room, my attending sat down quietly across from the mother, and gently asked a seemingly simple question: “What worries you most about his symptoms?”

She looked at her son, snotty but happy on the bed. “His runny nose. It’s just been going on for so long.”

My attending pursued, “And what worries you most about this?”

The mother met my attending’s gaze. “His sister had a runny nose just like this a few years ago, and everyone dismissed it, but it turned out to be a cerebral spinal fluid leak.” Her voice broke as her face flooded with emotion. “She had to go through so many surgeries, she almost died, and I am worried sick that her brother has the same thing.”

I almost dropped the chart from my hands. Even when I had asked the mother about family history, she’d said, “Everyone’s healthy.”

With one question, my attending opened up an entirely new perspective on the patient that dramatically changed our explanations and return precautions. My attending also carefully guided me through a thorough ear, nose, and throat exam, and when it was pronounced normal, the mother’s shoulders relaxed in relief. When she left, her child cheerfully waving goodbye, she gave my attending a hug.

Many years have passed since that brief encounter, but that one question still burns brightly in my mind. I am now the attending who teaches medical students and residents, and I remind them to always ask at each sick visit: “What worries you most about this?”

It’s a deceptively simple question, but the answers can alter patient management as much as any lab value or imaging study. In medical school, students are trained to inquire, “Why are you coming in today?” (to which parents may say, “He has fever”)—but without that key follow-up question they may miss the too-often-unspoken second part of that response: “…and we’re worried the fever could damage his brain.”

A provider can scan the presenting symptoms from the triage note and see “headache,” “stomachache,” “sleepy.” But if we teach doctors to ask that most-human of questions about those same chief complaints, they may get unexpected perspectives from their patients’ parents:

• “My neighbor’s little girl had a headache like this, and the next day she was dead of brain bleed.”

• “I didn’t want to mention this, but he got ahold of his brother’s anti-seizure medication right before he started throwing up.”